What About Us? Attitudes of Staff Members Involved in the Care of Patients who Self-Harm

What About Us? Attitudes of Staff Members Involved in the Care of Patients who Self-Harm

Article Title: Attitudes of Forensic Psychiatric Staff to Self-Harm Behaviors of their Female Patients | 2022, Vol. 21, No. 4, 361-371


Daphne O’Hara; Department of Psychology, Universite du Quebec a Trois-Rivieres, Quebec, Canada

Joao Da Silva Guerreiro; Department of Psychology, Universite du Quebec a Montreal and Mental Health Unity for Women Serving a Federal Sentence (Unit F-1), Institut National de Psychiatrie Legale Phillippe-Pinel, Quebec, Canada

Julie Lefebvre; Department of Psychology, Universite du Quebec a Trois-Rivieres, Quebec, Canada


The management of self-harm presents a major challenge in correctional and forensic psychiatric services, especially for women offenders, among whom it is reported to be highly prevalent. Even though staff play an important role in managing self-harm, few studies have evaluated their attitudes to this behavior. In order to understand the attitudes of staff to women’s self-harm, 16 staff members working in a forensic psychiatric hospital participated in semi-structured interviews designed to explore their experience in depth. The staff members presented, on the one hand, positive attitudes expressed as empathy, sensitivity, and positive feelings but, on the other hand, negative attitudes expressed in the form of preconceived ideas and negative feelings. Differences were also noted in their perceptions of the seriousness of self-harm. Self-harm behaviors seem to have a considerable impact not only on caregivers, but also on the entire care unit. Our study supports the importance of both professional support and training for staff who are exposed to this type of behavior. Clinical and research implications are discussed.


Attitudes; staff; self-harm; women offenders; forensic psychiatry

Summary of the Research

“…In the present research, self-harm behaviors refer to any actions done by a person with the goal of injuring herself but without suicidal ideation…Self-harm is an important issue because it has an impact on the security and well-being of both clientele and staff…Negative repercussions have been documented among staff members who had to deal with self-harm…including an increased risk of professional burnout and secondary traumatic stress…Staff working with people who engage in self-harm also experience a higher rate of negative emotions during their interventions, such as anxiety, feelings of powerlessness, irritability, frustration, and anger…These emotions may have a negative influence not only on their psychological well-being, but also on the quality of their interventions with the clients who display self-harm behaviors…The attitudes of staff to these behaviors may also affect the quality of their relations with patients and, consequently, the effectiveness of patient care and recovery…” (p. 361).

“At present, most of the studies on the attitudes of staff who deal with self-harm behaviors have been done among hospital personnel…and are limited to one geographic region, the United Kingdom…The phenomenon of self-harm is underexplored in forensic psychiatric services…especially in North America…The goal of the present exploratory study is to better understand the attitudes of forensic psychiatry staff to the self-harm behaviors of their female patients…The study took place at the Institut national de psychiatrie legale Philippe-Pinel (INPLPP), a high-security psychiatric hospital in Canada. Data collection was done in the Mental Health Unit for women serving a federal sentence (Unit F-1)…The sample comprised 16 staff members (8 women and 8 men) working in INPLPP’s Unit F-1…from five professional groups: specialized educators, nurses, psychologists, criminologists, and specialists in pacification and security…” (p. 362).

“…The data collected are consistent with those of previous studies on the adoption of positive and negative attitudes to self-harm behaviors…In the present study, these attitudes reflect, on one hand, empathy, sensitivity, and positive feelings and, on the other hand, preconceived ideas and negative feelings experienced during interventions. Our study highlights the complexity of the phenomenon and the ambivalence of the treating team regarding self-harm behaviors. According to the staff members we interviewed, multiple mutually interacting factors appear to be associated with attitudes on self-harm: personal factors (e.g., perceptions), professional factors (e.g., number of years of experience), and organizational factors (e.g., workload, team support, training, and supervision)” (p. 368).

“Even though the staff in this study were generally empathetic to the self-harm behaviors of their patients, there were various negative feelings among staff members…This research provides evidence that self-harm not only has a strong impact on the person performing it but also on that person’s peers and the care team. These behaviors occurred within a therapeutic relation that appeared to be strongly undermined by acts of self-harm. Important challenges on the part of staff were identified, among them the effectiveness of their intervention and the attribution of responsibility for these acts either to themselves…or to the patient engaging in self-harm…” (p. 368).

Translating Research into Practice

“Teamwork was identified as an important lever in interventions with people who practice self-harm...Conversely, lack of training was highlighted as a major issue by almost all of the participants. Thus, our study is consistent with previous studies that suggest that access to training would improve the knowledge and understanding of staff responding to self-harm…The care team’s feeling of self-efficacy, nourished by training on self-harm and the personality problems that underlie it, could be associated with the adoption of more positive attitudes to self-harm…Several authors have suggested the use of teaching methods that go beyond information sharing by integrating reflective and interactive components in training. To do this, they encourage group discussions, role play, and critical analyses of incidents…It is essential that future training be adjusted to the targeted needs of staff members…” (p. 368).

“Avoidance strategies were used by staff to deal with feelings created by acts of self-harm…it is worrying to note that the staff members were almost unanimous in recognizing the discomfort, even the distress, caused by acts of self-harm, but that this reality seemed to be rationalized or minimized in their daily practice…Given the extent of the negative emotions experienced by caregivers in their work with patients who self-harm and the way these emotions are reportedly managed by staff, it is important to work toward the validation of their emotions. This aspect should be addressed in future initiatives for multidisciplinary teams, especially by encouraging the creation of a space where staff members could share the experiences that had an emotional impact on the team, as suggested by several participants in our study” (p. 368-369).

“Several staff members reported having been seriously affected by at least one self-harm incident, which is a reminder of the potentially traumatic character of exposure to this kind of behavior. Our study corroborates previous work showing that it is crucial to promote the implementation of interventions to support staff in their work with this complex clientele…O’Connor and Glover (2017) emphasize the importance of debriefing meetings and point out that they can not only improve the well-being of staff but also relations with the patients. Team reflection on systemic issues (e.g., the impact on other patients, the role of the care team or the institution where care is given) and individual issues (e.g., issues related to personality disorders and their management) following self-harm incidents could promote the adoption of better management practices for these behaviors…Clinical supervision is also an important resource to enable staff to deal with their professional challenges in a safe environment and to enhance therapeutic interventions when working with patients who self-harm…” (p. 369).

Other Interesting Tidbits for Researchers and Clinicians

“Although there is no consensus on this matter within the literature, certain sociodemographic indicators are associated with the attitudes of staff to self-harm; they include age, sex, and number of years of experience…A study conducted by McCann et al., (2006) suggested that older and more experienced nurses possessed more positive attitudes toward self-harm patients. O’Connor and Glover (2017) proposed that it would be preferable to concentrate on the way in which staff engage with the relational issues of their patients rather than examining staff members’ socioeconomic background. These studies are consistent with other work on the association between a lack of training for staff and negative attitudes to self-harm…Although self-harm is the primary focus of this study, it is important to be aware that individuals who self-harm are at an increased risk of violence toward others…this adds to the complexity of managing self-harm behaviors” (p. 362).

Additional Resources

Trauma-informed Ethical Decision-Making: Employing the 10 Principles of Trauma-Informed Ethical Practice

Assessing & Managing Risk for Self-Directed Violence (Suicide)